Youth Suicide and Preceding Mental Health Diagnosis

This cross-sectional study assesses sociodemographics, precipitating circumstances, and suicide mechanisms associated with documented mental health diagnosis among youths aged 10 to 24 years who died by suicide.


Introduction
Suicide is the second leading cause of death for US youths aged 10 to 14 years and the third leading cause of death for youths aged 15 to 24 years, with nearly one-half due to firearms. 1 From 2010 to 2021, 71 820 youths aged 10 to 24 years died by suicide with a near 50% increase in annual suicide rates over this period. 1Prior studies indicate that less than one-half of youths who die by suicide have a previously documented mental health (MH) problem or diagnosis. 2,3No studies utilizing recent data have examined whether documentation of prior MH diagnosis varies by sociodemographic and clinical characteristics.
As youth suicide rates have increased, disparities have widened.Among racial and ethnic groups, American Indian and Alaska Native youths have the highest rate of suicide overall (41.9 per 100 000 youths in 2020) while the rate of suicide has risen the fastest among Black youths (6.9 per 100 000 youths in 2010 and 12.9 per 100 000 youths in 2020-an 87% increase). 1,4Racially and ethnically minoritized youths experience inequities in access to MH services, resulting in disparities in outcomes. 5,6][9][10][11] During the first year of the pandemic, there were significantly more suicides than expected among male youths, children aged 5 to 12 years, youths aged 18 to 24 years, non-Hispanic American Indian and Alaska Native youths, and Black youths, as well as more firearm suicides than expected. 12spite shifting patterns of MH service use and increased firearm accessibility, few studies have evaluated which population subgroups are most likely to have a known MH diagnosis prior to youth suicide.Early identification and documentation of an MH disorder, a known factor associated with increased risk of suicide, may facilitate timely targeted suicide prevention efforts and access to MH services. 13,14In the context of increased firearm access, identification of these intervenable characteristics is vitally important for suicide prevention.Therefore, our objective was to examine the association of sociodemographic characteristics, suicide mechanism, clinical characteristics, and precipitating circumstances with having a documented MH diagnosis among youth suicide decedents.

Study Design and Data Sources
This retrospective, cross-sectional study was determined exempt from human participants research and the requirement of informed consent by the institutional review board of Emory University and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. 15The study population included US youths aged 10 to 24 years that died by suicide between January 1, 2010, and December 31, 2021.We used mortality data from the National Violent Death Reporting System (NVDRS) Restricted Access Database.NVDRS is a state-based surveillance system that collects data on all violent deaths including suicide, homicide, legal

JAMA Network Open | Pediatrics
Youth Suicide and Preceding Mental Health Diagnosis intervention death, unintentional firearm death, and death of undetermined intent that might have been caused by violence. 16Data are collected from 3 required data sources: death certificates, coroner and medical examiner records, and law enforcement reports. 16We included data from all available states and territories that contribute data to NVDRS, which increased from 16 states in 2010 to 49 states, the District of Columbia, and Puerto Rico in 2021 (eTable in Supplement 1). 17At the time of the analysis, NVDRS data were available through 2021.Suicide cases were determined based on International Classification of Diseases, Tenth Revision (ICD-10) cause of death codes (X60-X84, Y87.0, and U03) and/or based on evidence from source documents, with the final manner of death assigned by trained NVDRS abstractors. 16Suicide was assigned if death resulted from use of force against oneself and a collection of evidence indicated that use of force was intentional. 16,18

Study Measures
The primary outcome was the presence of a previously documented MH diagnosis among youth suicide decedents.To identify this outcome, we utilized the MH problem variable defined by NVDRS as (1) the decedent has a current MH diagnosis as categorized by Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), not including from alcohol or other substance dependence, or (2) source documents (death certificate, coroner or medical examiner report, and police report) list the decedent as being treated for an MH problem, potentially from family member report or current prescription. 18ciodemographic characteristics included race (American Indian or Alaskan Native; Asian, Native Hawaiian, or Other Pacific Islander; Black; White; multiple race category, and other [defined as any race not otherwise specified] or unspecified), ethnicity (Hispanic or non-Hispanic), age group (10-14 years, 15-19 years, and 20-24 years), and sex (female and male).Race and ethnicity were reported from combined raw data available from source documents (including death certificates, coroner and medical examiner records, and law enforcement reports) and verified by NVDRS investigator teams.Acknowledging race and ethnicity are social constructs, and racially and ethnically minoritized populations often have inequitable access to MH services, race and ethnicity were included as covariates in the analyses. 19,20inical characteristics included MH variables such as depressed mood, suicidality (suicide disclosure, history of nonsuicidal self-harm or self-injury, history of suicidal thoughts, or attempts), and substance misuse (alcohol and/or substance abuse).These MH characteristics were considered separate from a documented MH diagnosis.Decedents were categorized as having depressed mood if the they were perceived by themselves or others as depressed at the time of death; the definition does not require a clinical diagnosis of depression or that depression directly contributed to death. 18ecipitating circumstances were identified per coroner or medical examiner and law enforcement reports as having contributed to suicide death.Decedents could have multiple precipitating circumstances.We included precipitating circumstances regarding interpersonal problems, other life stressors (such as criminal, civil legal, school, or financial) and recent crises (defined as within 2 weeks prior to death).Suicide mechanisms were defined as firearms; poisonings; hanging, strangulation, or suffocation; and other (which included motor vehicle, falls, and sharp or blunt instruments).
Location of suicide was categorized as home, other, or unknown.

Statistical Analysis
We conducted descriptive analysis with counts and frequencies of suicide deaths by sociodemographic and clinical characteristics, precipitating circumstances, location, and mechanism.
We performed χ 2 tests of proportions to assess differences in the proportion of suicide decedents with and without a documented MH diagnosis by sociodemographics, mechanism, and location.We used multivariable logistic regression to determine sociodemographic and clinical characteristics, precipitating factors, and mechanisms associated with the presence of a documented MH diagnosis.

Findings
This cross-sectional study of 40 618 youth suicide decedents from the Centers for Disease Control and Prevention National Violent Death Reporting System found 24 192 decedents (59.6%) had no previously documented mental health diagnosis and 19 027 (46.8%) died by firearm suicide.The odds of having a documented mental health diagnosis were lower among racially and ethnically minoritized youths and among youths who used firearms.Meaning These findings suggest that a critical need exists for comprehensive youth suicide prevention strategies, including early identification of mental health concerns, equitable access to mental health services, and universal lethal means counseling.
Youth Suicide and Preceding Mental Health DiagnosisWe constructed a model using the full cohort and then performed stratified analysis by age group.All models were adjusted for race, ethnicity, sex, and age group.Results were reported as adjusted odds ratios (aORs) and 95% CIs.All hypothesis testing was 2-sided, with statistical significance set at P < .05.All statistical analyses were performed with SAS version 9.4 (SAS Institute).Data analysis was conducted from January to November 2023.

Table 1 .
Sociodemographic Characteristics and Suicide Mechanisms by Documented Mental Health Diagnosis a Percentages by column.bPercentagesby row.cP< .001forallcomparisons.deOther included any race not otherwise specified.National Violent Death Reporting System follows US Department of Health and Human Services and Office of Management and Budget standards for race and ethnicity categorization. 21haracteristics

of Youths With and Without a Documented MH Diagnosis Among
youth suicide decedents, 16 426 (40.4%) had a documented MH diagnosis and 24 192 (59.6%) had no documented diagnosis.Across individual groups, White youths had the highest rate of MH diagnosis (13 153 youths [42.8%]) and American Indian or Alaska Native youths had the lowest rate (333 youths [28.0%]); among Hispanic youths, 1959 (36.7%) had an MH diagnosis.Slightly more than one-half of female youths had an MH diagnosis (4429 youths [52.4%]), compared with 11 994
a As reported in National Violent Death Reporting System data from coroner or medical examiner or law enforcement reports.bData for this variable were collected starting e Data for these variables were collected starting July 1, 2013.During that time, the total number of decedents was 33 594; 13 858 had a documented mental health diagnosis and 736 had no documented mental health diagnosis.male

Table 3
Among decedents with a documented MH diagnosis, the most common mechanism was hanging, strangulation, or suffocation (7017 decedents[42.7%]).Among decedents without a documented MH diagnosis, the most common mechanism was firearms (12 719 decedents[52.6%]).Among all decedents, 19 027 [46.8%] died by firearms.In the multivariable model, compared with Figure 2. Multivariable Model for Sociodemographic Characteristics and Suicide Mechanism Associated With Having a Documented Mental Health Diagnosis Stratified by Age Logistic regression model with adjusted odds ratio adjusting for race, ethnicity, and sex.Pacific Islander included Native Hawaiian or Other Pacific Islander.Other race included any race not otherwise specified or unspecified race.Hanging included strangulation or suffocation.OR indicates odds ratio.youthswhodiedby firearms, youths who died by poisonings (aOR, 2.78; 95% CI, 2.55-3.03);hanging,strangulation,or suffocation (aOR, 1.70; 95% CI, 1.62-1.78);andothermechanisms (aOR, 1.59; 95% CI, 1.47-1.72)hadhigheradjusted odds of having a documented MH diagnosis (Figure1).Likewise, within each age group stratum, youths who died by poisonings and hanging, strangulation, or suffocation had higher adjusted odds of having a documented MH diagnosis compared with those who died by firearms.

Table 3 .
Multivariable Model for Clinical Characteristics and Precipitating Circumstances Associated With Having a Documented Mental Health Diagnosis a Adjusting for race, ethnicity, age, and sex.bAs reported in National Violent Death Reporting System data from coroner or medical examiner or law enforcement reports.